PROCEDURE: Ultrasound and fluoroscopy guided tunneled hemodialysis catheter (Permacath) placement
INDICATION:
DATE:
OPERATORS: , MD (Attending)/ , MD (Fellow)
ACCESS SITE: Right internal jugular vein with ultrasound
MEDICATIONS: Versed mg IV, fentanyl mcg IV, and
CONTRAST: None
FLUOROSCOPY TIME: minutes
CATHETER: 15.5 French, cm tip to cuff catheter
COMPLICATIONS: None
TECHNIQUE:
The risks, benefits, and alternatives to the procedure and sedation were explained. Written informed consent was obtained. A timeout was performed.
The right neck and upper chest were prepped and draped in sterile fashion. Using local anesthetic and ultrasound guidance, the right internal jugular vein was punctured with a 21 gauge needle. An image was saved and stored to PACS.
A 0.018-inch wire was passed centrally and the needle exchanged for a 5 French transitional dilator. A 0.035-inch wire was advanced through the dilator and negotiated into the IVC. The skin tract was dilated and a 16 French dilator peel-away combination placed over the wire.
The soft tissues caudal and lateral to the sheath entry site were anesthetized with lidocaine with epinephrine. A dermatotomy was made and a tunneling tool brought from the dermatotomy to the venotomy. The catheter was brought through the tunnel.
During suspended respiration, the catheter was advanced through the peel-away and positioned centrally using fluoroscopy. The peel-away was removed and hemostasis achieved with manual compression.
The venotomy was closed with Dermabond and Steri-Strips applied. The catheter was secured with 2-0 Ethilon. An antimicrobial disc and sterile dressing were applied.
The catheter was aspirated, flushed, and heparinized per protocol. The procedure was well tolerated, and the patient was discharged in satisfactory condition.
FINDINGS:
- The right internal jugular vein is ultrasonographically patent. Needle entry was documented.
- The newly placed catheter has a smooth course with the tips terminating in the right atrium.
- There is excellent function with 20 ml syringes.
IMPRESSION:
Uneventful image guided placement of a right internal jugular tunneled hemodialysis catheter (Permacath) as described.
Frequently Asked Questions
What is a Permacath and why is it used?
A Permacath is a type of tunneled hemodialysis catheter used for long-term access to the bloodstream for dialysis treatment. It's typically inserted into the internal jugular vein and features a tunnel under the skin to minimize infection risks.
The procedure involves using ultrasound and fluoroscopy to guide the catheter placement. The right internal jugular vein is accessed, and the catheter is tunneled under the skin. The process includes puncturing the vein, dilating the skin tract, and positioning the catheter in the right atrium, ensuring proper function.
What are the risks associated with Permacath placement?
Potential risks include infection, bleeding, damage to nearby structures, and catheter malfunction. However, using sterile techniques and imaging guidance minimizes these risks. The procedure described was uneventful, indicating a low complication rate.
Why is ultrasound guidance important in Permacath placement?
Ultrasound guidance allows precise identification of the vein and surrounding structures, reducing the risk of accidental puncture or injury. It enhances the safety and efficacy of the procedure by ensuring accurate catheter placement.
What should a patient expect after a Permacath placement?
Patients can expect some soreness at the insertion site. The catheter is secured and dressed to prevent infection. Proper care involves keeping the site clean and dry, and regular follow-up is needed to ensure functionality and prevent complications.
How is a Permacath maintained after placement?
Post-procedure maintenance includes regular flushing with heparin to prevent clotting and changing the dressing to avoid infection. Monitoring for signs of infection or malfunction is essential, and any concerning symptoms should be reported to a healthcare provider.
What is the role of fluoroscopy in Permacath placement?
Fluoroscopy provides real-time X-ray imaging, helping to confirm the catheter’s position in the blood vessel and ensuring it reaches the desired location in the heart. This imaging technique is crucial for verifying correct placement and reducing complications.
What does it mean when a Permacath is 'tunneled'?
A 'tunneled' catheter means it is placed under the skin before entering the vein. This tunnel reduces infection risk and provides stable, long-term access for dialysis. The skin tunnel secures the catheter, preventing accidental removal or displacement.